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Daily bibliographic review of the Neurosurgery Department. La Fe University Hospital. Valencia, Spain

Efficacy of primary microvascular decompression versus subsequent microvascular decompression for trigeminal neuralgia

J Neurosurg 126:1691–1697, 2017

Trigeminal neuralgia (TN) is characterized by intermittent, paroxysmal, and lancinating pain along the distribution of the trigeminal nerve. Microvascular decompression (MVD) directly addresses compression of the trigeminal nerve. The purpose of this study was to determine whether patients undergoing MVD as their first surgical intervention experience greater pain control than patients who undergo subsequent MVD.

METHODS A retrospective review of patient records from 1998 to 2015 identified a total of 942 patients with TN and 500 patients who underwent MVD. After excluding several cases, 306 patients underwent MVD as their first surgical intervention and 175 patients underwent subsequent MVD. Demographics and clinicopathological data and outcomes were obtained for analysis.

RESULTS In patients who underwent subsequent MVD, surgical intervention was performed at an older age (55.22 vs 49.98 years old, p < 0.0001) and the duration of symptoms was greater (7.22 vs 4.45 years, p < 0.0001) than for patients in whom MVD was their first surgical intervention. Patients who underwent initial MVD had improved pain relief and no improvement in pain rates compared with those who had subsequent MVD (95.8% and 4.2% vs 90.3% and 9.7%, respectively, p = 0.0041). Patients who underwent initial MVD had significantly lower rates of facial numbness in the pre- and postoperative periods compared with patients who underwent subsequent MVD (p < 0.0001). The number of complications in both groups was similar (p = 0.4572).

CONCLUSIONS The results demonstrate that patients who underwent other procedures prior to MVD had less pain relief and a higher incidence of facial numbness despite rates of complications similar to patients who underwent MVD as their first surgical intervention.

Resolution of Oculomotor Nerve Palsy Secondary to Posterior Communicating Artery Aneurysms- Comparison of Clipping and Coiling

Advanced Technical Skills Are Required for Microsurgical Clipping of Posterior Communicating Artery Aneurysms in the Endovascular Era-0

Neurosurgery 77:931–939, 2015

Previous studies have attempted to determine the best treatment for oculomotor nerve palsy (ONP) secondary to posterior communicating artery (PCoA) aneurysms, but have been limited by small sample sizes and limited treatment.

OBJECTIVE: To analyze the treatment of ONP secondary to PCoA with both coiling and clipping in ruptured and unruptured aneurysms.

METHODS: Data from 2 large academic centers was retrospectively collected over 22 years, yielding a total of 93 patients with ONP secondary to PCoA aneurysms. These patients were combined with 321 patients from the literature review for large data analyses. Onset symptoms, recovery, and time to resolution were evaluated with respect to treatment and aneurysm rupture status.

RESULTS: For all patients presenting with ONP (n = 414) 56.6% of those treated with microsurgical clipping made a full recovery vs 41.5% of those treated with endovascular coil embolization (P = .02). Of patients with a complete ONP (n = 229), full recovery occurred in 47.3% of those treated with clipping but in only 20% of those undergoing coiling (P = .01). For patients presenting with ruptured aneurysms (n = 130), full recovery occurred in 70.9% compared with 49.3% coiled patients (P = .01). Additionally, although patients with full ONP recovery had a median time to treatment of 4 days, those without full ONP recovery had a median time to treatment of 7 days (P = .01).

CONCLUSION: Patients with ONP secondary to PCoA aneurysms treated with clipping showed higher rates of full ONP resolution than patients treated with coil embolization. Larger prospective studies are needed to determine the true potential of recovery associated with each treatment.

Prognostic Significance of Peritumoral Edema in Patients With Vestibular Schwannomas

Prognostic Significance of Peritumoral Edema in Patients With Vestibular Schwannomas

Neurosurgery 77:81–86, 2015

Peritumoral edema (PTE) in skull base meningiomas correlates to the absence of an arachnoid plane and difference in outcome. In vestibular schwannomas (VS), PTE and its significance for microsurgery and outcome have never been systematically evaluated.

OBJECTIVE: To evaluate whether PTE correlates with tumor characteristics, the presence of an arachnoid plane, and outcome.

METHODS: A retrospective study of the institutional database. PTE was evaluated on fluid-attenuated inversion recovery magnetic resonance images. Preoperative patient data and intraoperative tumor features (presence of tumor pseudocapsule, vascularity, degree of adhesion/invasion of the arachnoid) were noted. Outcome measures were completeness of removal, neurological outcome, and complication rate. These parameters in patients with PTE (group A) were correlated to those in matched series without edema (group B).

RESULTS: Thirty patients presented with PTE (5%). The mean VS size was 3.4 cm. No major differences in the degree of adhesion or presence of an arachnoid plane were found. VS with PTE were more frequently hypervascular (26.7% in group A vs 6.7% in group B). The presence of PTE in VS was not related to surgical radicality. VS with PTE had worse early postoperative facial nerve function, but at 12 months, there was no major difference. VS with PTE were prone to cause postoperative hemorrhages in the tumor bed.

CONCLUSION: PTE in VS does not correlate with the degree of tumor adhesion and the presence of an arachnoid dissection plane. The radicality of tumor removal and longterm functional outcome in patients with and without PTE was similar. VS with PTE are more vascular and prone to cause postoperative hemorrhages. Therefore, meticulous hemostasis is advisable.

Subtemporal transtentorial approach for recurrent trigeminal neuralgia after microvascular decompression via the lateral suboccipital approach

Subtemporal transtentorial approach for recurrent trigeminal neuralgia after microvascular decompression via the lateral suboccipital approach

J Neurosurg 122:1429–1432, 2015

Microvascular decompression (MVD) via lateral suboccipital craniotomy is the standard surgical intervention for trigeminal neuralgia (TN). For recurrent TN, difficulties are sometimes encountered when performing reoperation via the same approach because of adhesions and prosthetic materials used in the previous surgery.

In the present case report the authors describe the efficacy of the subtemporal transtentorial approach for use in recurrent TN after MVD via the lateral suboccipital approach. An 86-year-old woman, in whom an MVD via a lateral suboccipital craniotomy had previously been performed for TN, underwent surgery for recurrent TN via the subtemporal transtentorial approach, which provided excellent visualization of the neurovascular relationships and the trigeminal nerve without adhesions due to the previous surgery. Her TN disappeared after the MVD.

The present approach is ideal for visualizing the trigeminal root entry zone, and the neurovascular complex can be easily dissected using a new surgical trajectory. This approach could be another surgical option for reoperation when the previous MVD had been performed via the suboccipital approach

Microvascular decompression under neuroendoscopic view in hemifacial spasm

Microvascular decompression under neuroendoscopic view in hemifacial spasm

Acta Neurochir (2015) 157:329–332

We report microvascular decompression (MVD) under neuroendoscopic view in hemifacial spasm (HFS) patients with rostral- and perforator-type compression of the root exit zone (REZ) of the facial nerve.

Using either a wireless iPad Mini as a monitor on the microscope or a high-resolution monitor, microscopic and endoscopic views enabled MVD for complete cure of HFS with rostral-type compression (the offender compressing the REZ on the opposite rostral side to the operative approach) or perforator-type compression (the offender tethered to the REZ by the perforator).

MVD under neuroendoscopic view may offer more accurate MVD and complete resolution of HFS.

Delayed relief of hemifacial spasm after microvascular decompression

Delayed relief of hemifacial spasm after microvascular decompression- can it be avoided?

Acta Neurochir (2015) 157:93–99

Although microvascular decompression (MVD) surgery has been widely accepted as an effective treatment for hemifacial spasm (HFS), delayed relief cases have been frequently reported. Therefore, the value of an immediate redo MVD should be discussed.

Methods This study included 1,435 HFS patients who underwent MVD with intraoperative abnormal muscle response (AMR) monitoring from 2011 through 2013 at XinHua Hospital. These cases were analyzed retrospectively with emphasis on the postoperative outcomes and introaperative findings.

Results After MVD, 1,384 HFS patients obtained relief immediately. The 51 unrelieved patients underwent AMR monitoring again the next day; this was positive in 48 and negative in 3 patients. These three patients with negative AMR obtained relief spontaneously within a week. Among the 48 positive patients, 31 and 11 were underwent redoMVD within a week and 5–22 months, respectively, and all achieved relief after the second operation. Of the six remainig patients, two obtained relief within 2months and 4 remained unchanged in the up-to- 3-year’s follow-up period. In redoMVDs, insufficient decompression of the facial nerve accounted for the failure. Finally, in this database, the immediate postoperative cure rate was 96.4 %; with earlier redo MVD, the final cure rate could be increased to 99.9 %.

Conclusions Despite being a reasonable remedy for HFS in the hands of an experienced neurosurgeon, sometimes small vessels can be missed while managing the main offending arteries during MVDs, which might account for the delayed relief. Therefore, reexamination of the AMR is necessary for unimproved patients; if a positive result is recorded, an immediate redo MVD is suggested.

Surgical Management of Trigeminal Neuralgia: Use and Cost-Effectiveness From an Analysis of the Medicare Claims Database

SnapShotPNGOID_38_20121112T070408_110023

Neurosurgery 75:220–226, 2014

Trigeminal neuralgia is a relatively common neurosurgical pathology with multiple management options. Microvascular decompression (MVD) is nonablative and is considered the gold standard. However, stereotaxic radiosurgery (SRS) and percutaneous stereotaxic rhizotomy (PSR) are 2 noninvasive but ablative options that have rapidly gained support.

OBJECTIVE: To use Medicare claims data in conjunction with a literature review to assess the usage, effectiveness, and cost-effectiveness of the 3 different invasive treatments for trigeminal neuralgia.

METHODS: All of the claims of trigeminal neuralgia treatment were extracted from the 2011 5% Inpatient and Outpatient Limited Data Set. Current Procedural Terminology, 4th Edition/International Classification of Diseases, Ninth Revision codes for the 3 different surgical treatment modalities were used to further classify these claims. Kaplan-Meier survival curves in key articles were used to calculate quality-adjusted life years and costeffectiveness for each procedure.

RESULTS: A total of 1582 claims of trigeminal neuralgia were collected. Ninety-four (6%) patients underwent surgical intervention. Forty-eight (51.1%) surgical patients underwent MVD, 39 (41.5%) underwent SRS, and 7 (7.4%) underwent PSR. The average weighted costs for MVD, SRS, and PSR were $40 434.95, $38 062.27, and $3910.64, respectively. The qualityadjusted life yearswere 8.2 forMVD, 4.9 for SRS, and 6.5 for PSR. The cost per quality-adjusted life year was calculated as $4931.1, $7767.8, and $601.64 for MVD, SRS, and PSR, respectively.

CONCLUSION: This study shows that the most frequently used surgical management of trigeminal neuralgia is MVD, followed closely by SRS. PSR, despite being the most cost-effective, is by far the least utilized treatment modality.

Trigeminal neuralgia occurs and recurs in the absence of neurovascular compression

NVC-TN

J Neurosurg 120:1048–1054, 2014

Vascular compression of the trigeminal nerve is the most common factor associated with the etiology of trigeminal neuralgia (TN). Microvascular decompression (MVD) has proven to be the most successful and durable surgical approach for this disorder. However, not all patients with TN manifest unequivocal neurovascular compression (NVC). Furthermore, over time patients with an initially successful MVD manifest a relentless rate of TN recurrence.

Methods. The authors performed a retrospective review of cases of TN Type 1 (TN1) or Type 2 (TN2) involving patients 18 years or older who underwent evaluation (and surgery when indicated) at Oregon Health & Science University between July 2006 and February 2013. Surgical and imaging findings were correlated.

Results. The review identified a total of 257 patients with TN (219 with TN1 and 38 with TN2) who underwent high-resolution MRI and MR angiography with 3D reconstruction of combined images using OsiriX. Imaging data revealed that the occurrence of TN1 and TN2 without NVC was 28.8% and 18.4%, respectively. A subgroup of 184 patients underwent surgical exploration. Imaging findings were highly correlated with surgical findings, with a sensitivity of 96% for TN1 and TN2 and a specificity of 90% for TN1 and 66% for TN2.

Conclusions. Magnetic resonance imaging detects NVC with a high degree of sensitivity. However, despite a diagnosis of TN1 or TN2, a significant number of patients have no NVC. Trigeminal neuralgia clearly occurs and recurs in the absence of NVC.

The role of the cerebellopontine angle cistern area and trigeminal nerve length in the pathogenesis of trigeminal neuralgia

Role of CPA cistern and TN

Acta Neurochir (2013) 155:863–868

The aim of this prospective study was to evaluate whether the cerebellopontine angle (CPA) cistern area and trigeminal nerve cisternal length play a role in the pathogenesis of trigeminal neuralgia (TN).

Methods High-resolution 1.5 T magnetic resonance imaging of the posterior fossa was performed in 26 patients with TN and 18 age-matched healthy controls. Axial T2- weighted, three-dimensional constructive interference in steady-state (3D-CISS) was used to measure bilaterally the cross-sectional area of the CPA cistern and trigeminal nerve cisternal length.

Results In patients, the cross-sectional area of the CPA cistern and trigeminal nerve cisternal length was smaller on the affected side (p=0.04). Healthy controls tended to have larger cisternal areas and longer trigeminal nerve lengths than patients (p=0.059, p=0.071, respectively). Larger CPA cisternal areas tended to be seen in older patients. There was a strong correlation between the crosssectional area of the CPA cistern and the length of the trigeminal nerve (p=0.000).

Conclusions Smaller CPA cisterns and short cisternal trigeminal nerves impact the pathogenesis of essential TN by facilitating the neurovascular conflict, especially in younger patients. Trigeminal nerve cisternal measurement provides an easy and direct estimation of the CPA area. This information can be used for surgical planning and potentially for outcome prediction.

Current neurosurgical management of glossopharyngeal neuralgia and technical nuances for microvascular decompression surgery

Neuralgia

Neurosurg Focus 34 (3):E8, 2013

Glossopharyngeal neuralgia (GPN) is an uncommon facial pain syndrome often misdiagnosed as trigeminal neuralgia. The rarity of this condition and its overlap with other cranial nerve hyperactivity syndromes often leads to a significant delay in diagnosis.

The surgical procedures with the highest rates of pain relief for GPN are rhizotomy and microvascular decompression (MVD) of cranial nerves IX and X. Neurovascular conflict at the level of the root exit zone of these cranial nerves is believed to be the cause of this pain syndrome in most cases. Vagus nerve rhizotomy is usually reserved for cases in which vascular conflict is not evident.

A review of the literature reveals that although the addition of cranial nerve X rhizotomy may improve the chances of long-term pain control, this maneuver also increases the risk of permanent dysphagia and vocal cord paralysis. The risks of this procedure have to be carefully weighed against its benefits.

Based on the authors’ experience, careful patient selection with a thorough exploratory operation most often leads to identification of the site of vascular conflict, obviating the need for cranial nerve X rhizotomy.

Neurosurgery Department. “La Fe” University Hospital. Valencia, Spain

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